Every finding on record at Care Central VNA & Hospice

Based on record review and interview, the agency failed to ensure the comprehensive assessment was completed by the hospice interdisciplinary group no later than 5 calendar days after the election of hospice care for one patient(#5), out of a total of sample of 19 patients.Findings include: --- Review of the agency policy entitled, Comprehensive Assessment Content, approved February 2025, indicated the following:*The comprehensive assessment of the patient is completed by designated members of the Interdisciplinary Group (IDG) in consultation with the patient's attending physician no later than five (5) calendar days after the patient elects the hospice benefit. (Exception is by patient /family request.)Patient #5 was admitted to the agency in September 2025 with a diagnosis of malignant neoplasm of the thyroid gland.Review of the clinical record indicated the Comprehensive Assessment was completed on 9/26/25.During an interview on 10/8/25 at 2:25 P.M., after reviewing the clinical record, the Hospice Officer said the Comprehensive Assessment was not completed within the five calendar days after the patient was admitted to the agency, as required.

Based on document review and interview, the agency failed to ensure a review of all medications the patient is currently using included allergies in order to identify any potential adverse effects, drug reactions or potentially significant side effects for 2 patients (#3 and #6), out of a total sample of 19 patients.Findings include: --- Review of the agency policy, titled, Comprehensive Assessment Content, last reviewed 1/2025, included the following:The comprehensive assessment identifies the physical, psychosocial, emotional and spiritual needs of the patient related to the terminal illness that must be addressed in order to promote the patient's well-being, comfort and dignity throughout the dying process.1. The comprehensive assessment of the patient consists of discipline-specific assessment tools that address the following factors:f. A review of all the patient's prescription and over-the-counter drugs, herbal remedies and other alternative treatments that could affect drug therapy.2. Each assessment tool is designed to obtain information related to the patient's history, current status, problems, and needs and contain data elements for the collection of information related to patient outcomes.1. Patient #3 was admitted to the agency in September 2025 with a diagnosis of Heart Failure.Review of the referral summary form indicated that Patient #3 was allergic to carbamazepine (used to treat seizures or neuropathic pain), Xarelto (blood thinner), Eliquis (blood thinner), Vyndaqel (used to treat heart disease), penicillin (antibiotic) and simvastatin (used to lower cholesterol).Review of the physician ordered Hospice Certification and Plan of Care (POC) for certification period 9/17/25 to 10/3/25 indicated there were no known allergies.During an interview on 10/7/25 at 1:30 P.M., the Hospice Officer said that the allergies from the referral should have been identified and listed in the medical record.2. Patient #6 was admitted to the agency in February 2025 with a diagnosis of Hypertensive heart disease with Heart Failure.Review of the referral summary form indicated that Patient #6 was allergic to penicillin, bee stings, and metformin (used to treat elevated blood sugar levels).Review of the physician ordered Hospice Certification and Plan of Care for certification periods 2/19/25 to 4/19/25, 6/19/25 to 8/17/25 and 8/18/25 to 10/16/25 indicated there were no known allergies.During an interview on 10/8/25 at 9:00 A.M., the Hospice Officer said that allergies should have been listed in the medical record.

Based on record review, policy review and interview, the agency failed to ensure an initial bereavement assessment was completed for 2 patients (#1 and #12), out of a total sample of 19 patients.Findings include: --- Review of the agency's policy entitled, Bereavement Services and Assessment, dated May 2025, indicated the following:*Assess bereavement risk upon admission and on an ongoing basis to identify survivor risk factors utilizing the Bereavement Risk Assessment and Plan of Care Tool.*Complete the comprehensive bereavement assessment to address anticipatory grief needs within five days from the start of care and as appropriate.*Document all assessment care and services in the electronic medical record.1.Patient #1 was admitted to the agency in September 2025 with a terminal diagnosis of senile degeneration of the brain (progressive decline in cognitive abilities that occurs with aging) and required hospice services.Review on the clinical record indicated an initial bereavement assessment had not been completed.During an interview on 10/7/25 at 3:25 P.M., the Hospice Officer said the initial bereavement assessment had not been completed within 5 days from the start of care, as required.2.Patient #12 was admitted to the agency in December 2024 with a terminal diagnosis of Hypertensive Heart Disease and Heart Failure (prolonged high blood pressure that damages the heart and leads to heart failure) and required hospice services.Review of the clinical record indicated the initial bereavement assessment was completed on 12/23/24, 14 days after the start of care.During an interview on 10/8/25 at 1:50 P.M, the Hospice Officer said nursing should have completed the assessment within the first 5 days from the start of care when the social worker had not completed it. She said the bereavement assessment was completed late, and not within 5 days from the start of care, as required.

Based on record review, policy review and interview, the agency failed to ensure hospice care and services furnished to patients and their families followed an individualized written plan of care established by the hospice interdisciplinary group in collaboration with the attending physician (if any), the patient or representative, and the primary caregiver in accordance with the patient's needs if any of them so desire, for one patient (#13), out of a total sample of 19 patients.Findings include: --- Review of the agency's policy entitled, Comprehensive Assessment Content, dated February 2025, indicated the following:*The comprehensive assessment identifies the physical, psychosocial, emotional and spiritual needs of the patient related to the terminal illness that must be addressed in order to promote the patient's well-being, comfort and dignity throughout the dying process.*The Interdisciplinary Group (IDG) uses information obtained from the comprehensive assessment tools to develop an effective plan of care with interventions that address the identified needs of the patient/caregiver.Patient #13 was admitted to the agency in November 2024 with a terminal diagnosis of Hypertensive Heart Disease with Heart Failure (prolonged high blood pressure that damages the heart and leads to heart failure) and required hospice services.Review of the physician ordered Hospice Certification and Plan Of Care (POC), dated 11/23/24 through 2/20/25, indicated the following:-Skilled Nurse Visit (SNV): 1 SNV a week for 14 weeks, and 4 as needed (PRN) visits for symptom management.Review of the clinical record indicated a PRN SNV was made on 11/29/24 due to a fall the patient sustained while trying to urinate. The note further indicated a Foley Catheter (FC-a thin flexible tube inserted into the urethra to drain urine from the bladder to outside the body) was inserted and caregiver was educated on catheter care and services.Review of the physician ordered POC did not include orders to insert a FC, nor care and services to maintain it.During an interview on 10/8/25 at 10:15 A.M., Nurse #1 said a physician order should have been obtained to insert the FC (including size and balloon size) as well as care and services to maintain it.